Massive suprachoroidal hemorrhage during cataract surgery: case report

A massive suprachoroidal hemorrhage is defined as a hemorrhage in the suprachoroidal space of sufficient volume either to cause extrusion of intraocular contents outside of the eye or to force the inner retinal surfaces into apposition ('kissing'). This is a very rare but one of the most serious complications of the intraocular surgeries. The authors describe a case of 84-year-old woman, who developed a massive suprachoroidal hemorrhage during cataract surgery. In our case, the main reason of expulsive hemorrhage development was a Valsalva effect, caused by unexpected cough during surgery. In a Valsalva maneuver, a sudden increase in venous pressure may lead to vessel-wall rupture, by an apparently excessive pressure gradient across the vessel wall. We present clinical and echographical study of this patient.     

Massive suprachoroidal hemorrhage: secondary treatment and outcome

PURPOSE: Massive suprachoroidal expulsive hemorrhage (SCH) is a dramatic and devastating intraocular complication of intraocular surgery and trauma that can result in total loss of vision. The aim of our study was to present the results of secondary surgical treatment of eyes following massive SCH. PATIENTS AND METHODS: We treated 10 patients suffering from massive SCH by combined radial sclerotomies for suprachoroidal drainage and vitrectomy with use of perfluorocarbon and instillation of silicone oil. We analyzed the clinical characteristics, visual acuity and anatomical status before and after secondary treatment. RESULTS: Visual acuity of all eyes suffering from SCH was light perception. Postoperatively five patients with SCH showed either no improvement of function or visual acuity of counting fingers. An increase in visual acuity to maximal 0.1 was seen in four eyes; one patient achieved 0.6. With a minimum of 6 months' follow-up, four eyes developed hypotony, two eyes became phthisical, and in two eyes recurrent traction retinal detachment occurred. CONCLUSIONS: Secondary treatment by combined suprachoroidal drainage by sclerotomies and vitrectomy should be performed to minimize the damaging effect of choroidal hemorrhage.     

Massive suprachoroidal hemorrhage in penetrating keratoplasty

We studied the frequency of massive suprachoroidal hemorrhage during and after penetrating keratoplasty. Nine cases of intraoperative or immediately postoperative massive suprachoroidal hemorrhage were identified in 830 consecutive patients (1.08%) undergoing penetrating keratoplasties at the Manhattan Eye, Ear, and Throat Hospital over a 2 1/2-year period. Six of the nine patients had atherosclerotic disease or hypertension, six of nine patients had glaucoma, and eight of nine patients had undergone previous intraocular surgery. Surgery was performed under general anesthesia in 714 patients, and four of these patients (0.56%) suffered hemorrhages. Five of 116 (4.3%) local anesthesia patients experienced expulsive choroidal hemorrhage. The increased resistance to venous outflow associated with retrobulbar anesthetic injection may significantly contribute to the risk of massive suprachoroidal hemorrhage.     

Appositional suprachoroidal hemorrhage: a case-control study

PURPOSE: To identify the risk factors, prognostic factors, and clinical outcomes of patients with perioperative appositional suprachoroidal hemorrhage (ASCH). DESIGN: Case-control study. SETTING: Tertiary referral center. METHODS: Subjects included all patients with perioperative ASCH documented by B-scan ultrasound between May 1990 and March 2001. Two or three control patients were selected for each case, matched by surgeon, procedure, and date of surgery within 1 month. Surgery was performed as necessary. main outcome measures. The odds of ASCH associated with clinical risk factors. secondary outcome measure: visual acuity. RESULTS: Thirty-seven cases with ASCH were identified. Ninety-two procedure- and surgeon-matched control subjects (2.48:1) were selected. Twenty-six cases (71%) of ASCH were related to a glaucoma operation. Risk factors for the development of ASCH included previous vitrectomy (P = .003, odds ratio of 12) and older age (P = .007, odds ratio 1.57/decade of increasing age). Hypertension was found to be protective (P = .02, odds ratio of 0.33). Factors associated with a poor visual outcome in patients with ASCH included apposition >30 days (P = .01), history of uveitis (P = .04), history of dry age-related macular degeneration (P = .05), and history of extracapsular cataract extraction (P = .05). Median pre-ASCH visual acuity was 20/100, and final median visual acuity was 20/1600. CONCLUSIONS: Risk factors for the development of ASCH include previous vitrectomy and older age. Patients with these risk factors should be informed of their greater chance of poor visual acuity and anatomic outcomes secondary to the development of ASCH.     

Massive suprachoroidal hemorrhage. Follow-up and outcome of 30 cases

The authors studied the records of 30 patients who suffered a massive suprachoroidal hemorrhage during cataract surgery. Immediate development of a retinal detachment (RD) is a very bad prognostic sign. In none of 12 such cases could the retina be reattached. Retinal complications developed in five of six patients who had vitreous incarceration and who did not have vitrectomy as opposed to only one of seven who underwent vitrectomy along with drainage of the hemorrhage. If vitreous is incarcerated in the cataract incision, drainage of the hemorrhage without vitrectomy is a dangerous procedure.     

Massive suprachoroidal hemorrhage with retinal and vitreous incarceration; a vitreoretinal surgical approach

Suprachoroidal hemorrhage(SH) may cause the expulsion of the intraocular contents. Vitreous incarceration in the wound and retinal detachment with SH are extremely poor prognostic signs. Treatment modalities depend on the severity of eye damage. This particular patient had "kissing" hemorrhagic choroidal detachment which completely filled the vitreous cavity after cataract surgery. It seemed to be inoperable. Secondary surgery was delayed 3 days to lower IOP to normal levels. The eye underwent anterior drainage sclerotomy under constantly-maintained limbal or pars plana infusion fluid line pressure. The authors performed a pars plana vitrectomy, followed by perfluorocarbon liquid injection and a silicone oil tamponade. After this surgical approach, the patient attained an attached retina and a visual acuity of 5/200 at the 3 month follow-up.     

Massive suprachoroidal hemorrhage during pars plana vitrectomy associated with Valsalva maneuver

PURPOSE: To report the intraoperative occurrence of massive intraocular suprachoroidal hemorrhage associated with Valsalva maneuver. METHODS: Retrospective, multicenter study of patients who developed massive choroidal hemorrhage associated with Valsalva maneuver during vitrectomy. RESULTS: Massive intraoperative suprachoroidal hemorrhage in seven patients (seven eyes) involved three men and four women with a median age of 52 years (range, 26 to 82 years). General anesthesia was used in six of seven cases. Coughing or "bucking" on the endotracheal tube during general anesthesia or severe coughing during the one vitrectomy performed under local anesthesia was associated with massive suprachoroidal hemorrhage. In five of seven eyes, this occurred near the end of surgery, after air-fluid exchange but before sclerotomy closure. Scleral plugs were immediately placed, and sclerotomy closure was performed exigently. Immediate posterior sclerotomy was performed on five of seven eyes; an additional patient underwent posterior sclerotomy postoperatively. After median follow-up of 18 months (range, 3 to 36 months), final visual acuity was no light perception in four eyes, light perception in one eye, 20/250 in one eye, and 20/20 in one eye. Four eyes became phthisical. CONCLUSIONS: Valsalva maneuver during pars plana vitrectomy may result in massive suprachoroidal hemorrhage with disastrous visual consequences. Precautionary measures to prevent coughing or "bucking" on the endotracheal tube during general anesthesia, or a prolonged episode of coughing during local anesthesia, may prevent this potentially devastating complication.     

Delayed massive suprachoroidal hemorrhage after retinal detachment surgery: case report

Massive suprachoroidal hemorrhage may occur at surgery, early postoperatively or may be delayed. The authors describe a case of 79-year-old woman, who developed a massive suprachoroidal hemorrhage in 72 hours after retinal detachment surgery. In our case, the main reason of suprachoroidal hemorrhage development was postoperative hypotony and occurrence of a lot of factors such hypertension, diabetes, high myopia, pseudophakia, which predispose to hemorrhage. This case is very rare but interesting because of its multifocal pathogenetical mechanism.     

暴发性脉络膜上腔出血的研究进展

暴发性脉络膜上腔出血（expulsive suprachoroidal hemorrhage,ESCH）是内眼手术少见的最严重并发症之一,可累及睫状体、玻璃体、视网膜,可致视力完全丧失。其发病机制尚不清楚,但与脉络膜组织成分及血供相关。既往研究表明,ESCH最重要的诱发因素之一是眼压突然下降,多出现于白内障、青光眼、玻璃体切除手术的术中及术后。眼部B超可诊断ESCH,并且可观察脉络膜上腔凝血液化的程度,这有助于明确手术时机。手术是ESCH最重要的治疗方式,早期行脉络膜上腔引流手术可挽救残存视力,但不同引流方式的效果存在争议。术前重视危险因素管理,术中谨慎操作,及时发现并有效处理可避免ESCH的严重后果。（国际眼科纵览,2022, 46：522-527）     

Clinicopathological study on suprachoroidal and supraciliary hemorrhage during enucleation

PURPOSE: To investigate the pathogenesis of suprachoroidal and supraciliary hemorrhage that might have been induced during enucleation. METHODS: A histopathological examination of 392 enucleated eyeballs was carried out and 8 eyeballs with suprachoroidal and supraciliary hemorrhage were selected for further clinicopathological examination. RESULTS: Among 14 eyeballs with severe acute intraocular inflammation, 7 eyeballs with suprachoroidal and supraciliary hemorrhage were found and one other such eyeball was seen among 53 with neovascular glaucoma. Among these 8, there was one case of prolapse of intraocular tissue with severe hemorrhage into the suprachoroidal and supraciliary spaces; 4 cases of severe hemorrhage into the suprachoroidal and supraciliary spaces without prolapse of intraocular tissue; and 3 cases of mild hemorrhage into the suprachoroidal or supraciliary spaces. CONCLUSIONS: In the eyeballs with severe acute intraocular inflammation, intraocular pressure was elevated and the blood vessels were weakened by inflammatory cell infiltration. During enucleation external forces affected the blood vessel wall of the ciliary arteries and vortex veins, and the breakdown of vessel walls might have been the cause of the suprachoroidal and supraciliary hemorrhage.     

内眼手术中脉络膜上腔出血

为探讨内眼手术中脉络膜上腔出血的临床特点及手术治疗与预后的关系，对１３例脉络膜上腔出血进行了回顾性分析。临床检查和Ｂ超显示：全部病例都有玻璃体出血，大部分病例有环周脉络膜上腔出血和前房出血而无视网膜脱离。４例做了后巩膜切开引流术，４例做了玻璃体视网膜手术，结果３例视力为０．０５～０．１２，１例为手动，其余均完全失明。表明内眼手术中脉络膜上腔出血预后差。玻璃体视网膜手术在部分病例可挽救眼球并获得有用的视力。关键在于认识危险因素并加强预防。     

Spontaneous expulsive suprachoroidal hemorrhage.

PURPOSE: To present a 90-year-old patient with spontaneous expulsive suprachoroidal hemorrhage (SESCH). This unique case suggests a mechanism of SESCH, which is still under debate. METHODS: The patient, who had corneal inflammatory disease and diabetes mellitus, atherosclerosis, and glaucoma, presented with active ocular bleeding and expulsion of intraocular tissues. Almost the entire cornea was absent, except for several small and irregular areas in its periphery. Histopathologic evaluation of the eviscerated contents was performed. RESULTS: Clinicopathologic evaluation revealed acute inflammation of the corneal remains as well as intraocular inflammation. Inflammatory necrosis of choroidal vessels was evident. CONCLUSION: The findings point to the assumption that choroidal bleeding, secondary to vascular inflammatory necrosis, was the initial event in this case of spontaneous expulsive suprachoroidal hemorrhage. Presumedly, the intraocular pressure level was very high owing to continuous bleeding, which could result in a very large, rather than localized, tearing of the peripherally inflamed cornea.     

Acute suprachoroidal hemorrhage during phacoemulsification

We present a case of acute suprachoroidal hemorrhage that developed during routine phacoemulsification in an 85-year-old patient after uneventful administration of periocular anesthesia. Pre-existing risk factors included advanced age, glaucoma, myopia, and hypertension. The scleral tunnel prevented major expulsion of intraocular contents; however, raised intraocular pressure prevented intraocular lens implantation. The rarity of this condition raises questions regarding the further management and precautions related to it.     

巩膜切开术治疗严重眼外伤脉络膜上腔出血

目的评价巩膜切开术治疗严重外伤眼脉络膜上腔出血的疗效。方法对18例（18眼）因严重眼外伤致脉络膜上腔出血行巩膜切开联合玻璃体切除术治疗。在睫状体平坦部做巩膜切口,必要时于赤道前做放射状巩膜切口引流脉络膜上腔积血,然后行玻璃体切除术,术终眼内填充气体或硅油。结果经睫状体平坦部切口脉络膜上腔积血引流充分者11眼;7眼需要另外做放射状巩膜切口引流,其中3眼完全复位,4眼部分复位。2眼因合并脉络膜破口,术后硅油进入脉络膜上腔。2眼因眼球萎缩而摘除眼球。结论巩膜切开术可以有效引流眼外伤所致脉络膜上腔出血。有脉络膜破口的出血性脉络膜脱离是治疗的难点,预后差。     

眼球破裂伤合并脉络膜上腔出血患者的手术疗效分析

目的 初步评价眼球破裂伤合并脉络膜上腔出血患者的手术治疗效果。方法 对17例（17只眼）因眼球破裂伤致脉络膜上腔出血的患者行Ⅱ期手术治疗,玻璃体腔内灌注BSS,由睫状体平坦部行巩膜切口引流脉络膜上腔积血,然后经睫状体平坦部行玻璃体切除联合视网膜复位术,术中眼内填充气体或硅油。结果 17例患者均成功引流脉络膜上腔积血,术后随访3－27个月,15例患者视网膜和脉络膜在位,眼球保存率88．2％,视力较术前有所提高;2例患者视网膜再脱离,眼球萎缩。结论 经Ⅱ期手术引流脉络膜上腔积血及玻璃体切除,视网膜复位术,大部分严重的眼外伤合并脉络膜上腔出血的患者可保留眼球,甚至恢复一定的视力。     

Favorable outcome after choroidal drainage for postoperative kissing suprachoroidal hemorrhage following trabeculectomy in a high myopic vitrectomised eye

A 39-year-old lady with past history of vitreoretinal surgery for retinal detachment and cataract surgery with Intraocular lens implantation was diagnosed as uncontrolled glaucoma. She had high myopia. She underwent Trabeculectomy and following which she presented with massive suprachoroidal hemorrhage in the first postoperative day with severe loss of vision. This case depicts the risk of suprachoroidal hemorrhage in a high myopic vitrectomised eye following glaucoma filtration surgery. It also demonstrates a favorable outcome following intervention for postoperative Suprachoroidal hemorrhage. At present, there is no evidence in literature of such event in a high myopic Vitrectomised eye following Trabeculectomy.     

Modified posterior drainage of post-operative suprachoroidal hemorrhage

Purpose:To study the anatomical and functional outcomes of trans-conjunctival 23G or 25G cannula-guided modified posterior passive drainage of post-operative suprachoroidal hemorrhage (SCH).Methods:A retrospective study was done on 15 eyes in the last nine years. Vitrectomy with perfluorocarbon liquid injection to push SCH from inside along with 23G or 25G cannula-guided passive drainage of SCH was performed by making multiple sutureless posterior sclerotomies at 10–15 mm behind the limbus. Postoperatively, best corrected visual acuity (BCVA), intraocular pressure (IOP), and posterior segment findings were compared from pre-operative findings.Results:Mean age at presentation was 64.93 ± 7.62 years. Complete resolution of SCH with attached retina was achieved in 60% (9/15) of cases. Mean pre-operative BCVA of Log MAR 2.82 ± 0.21 improved to mean post-operative BCVA Log MAR 1.04 ± 0.53 (P < 0.001). Mean pre-operative IOP of 27.87 ± 8.67 mmHg improved significantly to post-operative IOP of 10.2 ± 5.16 mmHg (P < 0.001). Silicone oil removal was possible in 11/15 (73.33%) cases.Conclusion:Posterior passive drainage of post-operative SCH by multiple sclerotomies using 23G or 25G cannulas can salvage these eyes with both anatomical and functional recovery.